Liverpool Care Pathway - The Perception Of Dying And The Perception Of the Dying

Compassion and care dumbed down by a pathway and patients dumbed down to expect nothing and less by those who apply it...

That is not a state of affairs to admire and to pursue.

To make a judgement founded solely upon perception of impending death – even though that perception may be a consensus of multi-disciplinary opinion – is a grave error that permits further error to intervene and to proceed. A ‘poor outcome’ decision will as surely consign to the grave as a steamroller rolling free downhill gathers momentum. Attitudes and expectations are altered subtly but utterly and completely. Thus -

This is Mrs. Kathleen Vine's granddaughter:

"I was being left to die. If it hadn't been for my family I would be dead now. I would just have been another statistic on the books."        - Mrs. Kathleen Vine

"When she was on morphine she was confused and not making sense - which was totally out of character. But they took her confusion as a sign of dementia.

"We were brought up to think that doctors and nurses know more than us about medical matters. So, our initial reaction was to believe the medical staff and we were almost made to feel silly for questioning them," said Helen.

"On the day after she'd gone onto the Liverpool Care Pathway, we were visited by an end of life nurse. And he was ever so nice - I mean, the nursing staff were all lovely..." -The Report

A lovely "end of life nurse" who is trained in grooming counselling. Fortunately for Mrs. Vine, the drugs had taken insufficient effect. She woke. That saved her life. That "lovely end of life nurse" would have persisted with his charm until he had succeeded in grooming his subjects into planning the funeral.

Medicine is an art as well as a science but neither may function well without the other. Medicine may be a leap of understanding as well as perceptive diagnosis but neither may function well without the other.

Compassion and care dumbed down by a pathway and patients and their loved ones dumbed down to expect nothing and less by those who apply it is not a state of affairs to admire or to pursue.

There is an extraordinary prevalence of pneumonia-related deaths reported here...

This is taken from The suppressed report of the Barton Care Pathway –

Most patients had received an opiate before death (Table 2.5). The most common pattern was initial use of Oramorph, followed by diamorphine subcutaneously. When used in a syringe driver in this way, diamorphine was invariably accompanied by other drugs. In 1988, diamorphine was used in combination with atropine, but in subsequent years it was combined with hyoscine and midazolam. In one case, the duration of opiate medication could not be determined from the records. The other 76 who received opiates were administered the drugs for a median of four days. - The suppressed report of the Barton Care Pathway

Should pneumonia be considered as a prompt to seek further for cause of death than perceived as an indicator of death? The cause of death may be determined to be the fall when the determining factor may have been the push.

One patient, Brian Cunningham, was admitted to the hospital for a routine examination at the age of 79 in September 1998. Although he was frail, his stepson, Charles Farthing, said he was kept in hospital only because of bed sores. Yet six days later, he was dead. 

Farthing saw him on the Monday he was admitted. He was sitting up and requesting chocolate and a box of tissues. 

Farthing added: "I had a phone call to say Brian was being very difficult and they had to give him something to calm him down. When I went back on Wednesday, he was comatose. There was a black box attached to him with a bleeping noise, pumping in drugs." When Farthing protested, the sister on the ward said the patient needed the treatment for his pain 

Farthing was told his stepfather died of bronchial pneumonia. He later successfully argued for a post-mortem examination, but no attempt was made to ascertain drug levels in the body.
- The Guardian

Benzodiazepines are widely used in palliative care.

The patient had died of bronchopneumonia in 9 December 1998, and the complaint was that the patient had received excessive doses of morphine, had not received reasonable medical and nursing care, and had been allowed to become dehydrated. - The suppressed report of the Barton Care Pathway

Features of opiate toxicity may be interpreted as un-controlled pain, leading to the administration of more opiate medication. The consequences are increased sedation, dehydration and further toxicity. (O’Neill and Fallon, 1997)

From the BMJ archives -

"... It matters not whether we discuss continuous deep sedation or a lesser degree of sedation. Any level of sedation, even a small dose of morphine in the frail elderly, can result in dehydration that may prove fatal if left untreated for days. Unfortunately palliative carers tend to overlook this basic fact. They prefer to discuss sedation and hydration as separate issues without linking the two in their minds. In doing so they are in danger of missing or evading the point, which is that sedation without hydration kills."

This is THORAX - An International Journal of Respiratory Medicine -

Abstract

Objectives Benzodiazepines have been associated with an increased incidence of infections, and mortality from sepsis, in the critically ill. Here, we determined the effect of community use of benzodiazepines on the occurrence of, and mortality following, pneumonia.

Methods A nested case-control study using 29 697 controls and 4964 cases of community-acquired pneumonia (CAP) from The Health Improvement Network, a UK primary care patient database (2001–2002), investigated the association between benzodiazepines and pneumonia occurrence using conditional logistic regression. Cox regression was then used to determine the impact of benzodiazepines on mortality in the 4964 cases of CAP. Results are presented as adjusted OR, adjusted HR and 95% CI.

Results Exposure to benzodiazepines was associated with an increased risk of pneumonia (OR 1.54, 95% CI 1.42 to 1.67). Individually diazepam, lorazepam and temazepam, but not chlordiazepoxide, were associated with an increased incidence of CAP. As a class, benzodiazepines were associated with increased 30-day (HR 1.22 (95% CI 1.06 to 1.39)) and long-term mortality (HR 1.32 (95% CI 1.19 to 1.47)) in patients with a prior diagnosis of CAP. Individually diazepam, chlordiazepoxide, lorazepam and temazepam affected long-term mortality in these patients.

Conclusions Benzodiazepines were associated with an increased risk of, and mortality from, CAP. These hypothesis generating data suggest further research is required into the immune safety profile of benzodiazepines.

…the proportion of patients at Gosport who did receive opiates before death is remarkably high, and it is difficult to accept that the practice of almost routine use of opiates before death, dating from 1988 or earlier, merely represents clinical practice in advance of practice elsewhere. The practice may be summed up in the words found in many clinical records – ‘please make comfortable’. This phrase also points to a prevailing attitude or culture of limited hope and expectations towards the potential recovery of patients in Gosport. But in some patients, a different attitude that might be phrased ‘determined rehabilitation’ could well have led to a different outcome. - The suppressed report of the Barton Care Pathway

"...it is difficult to accept..." This is 2003. This is the Barton Care Pathway. The LCP is yet to be rolled out. In retrospect, all becomes clear.

"A culture of limited hope and expectations..." That describes perfectly the culture of the EoLC Strategy. It is downsizing care expectations. The programme is well advanced; the groomers are already groomed.

To quote a twit tweet from one of Chairman Ellershaw's Red Guards: "Come on - EoLC!"

Depending on the structure and dynamics of the so-called multi-disciplinary team, a wrong diagnosis may be readily confirmed and the error compounded. A perception of dying will - at once erroneous and foolhardy though it may well be - by its certain outcome, death, be taken as confirmation of the diagnosis. Pythonesque!

"The report highlights a myriad of challenges of mainstreaming palliative care: the fact that most common chronic diseases (unlike cancer) have uncertain prognoses, which makes assessment of the need for palliative care difficult..." - "The Solid Facts: Palliative Care" edited by Elizabeth Davies and Irene J. Higginson

The Telegraph reported on a study in The Lancet which demonstrates that, using the illustration of cardiac op outcomes, where there is better care there are always better outcomes . Patients are placed at risk because of a "one-size fits all" approach that is "ingrained" in the NHS. This is interesting. This study is a very good argument against pathways in general and palliative care pathways in particular.

The perception of the dying, likewise, might be misleading and misinformed. It is wholly a subjective view, reported by the perceiver of the death and not by the person who has died. A sedated patient is not in a position to complain. A dead patient cannot complain.

Benzodiazepines (Midazolam, Lorazepam, Diazepam, temazepam, alprazolam)

The Fix reports on these Benzodiazepines -

Temazepam: Sold in the U.S. under the brand name Restoril, this benzo was developed and approved in the 1960s as a short-term treatment for insomnia. It is basically what is commonly called a “knockout drop.” Taken even in relatively modest dosages, temazepam can produce a powerfully hypnotic effect that numbs users and makes them extremely compliant and susceptible to control. But thanks to the “practice of medicine exception” physicians can prescribe it for anything they want.

During the Cold War, the Soviet Union reportedly used temazepam extensively to keep political dissidents in a drugged-out state in government-run psychiatric hospitals. Both the CIA and the KGB are also said to have also used the sleeping pill in prisoner interrogations and in research into mind-control, brainwashing and social engineering.

Temazepam is sometimes referred to as a “date rape” drug, and it figures frequently in drug-related crimes of violence. In the drug world underground, where it is often sold as an alternative to heroin and crack cocaine, it goes by such street names as “tams,” “Vitamin T,” “terminators,” “big T,” “mind eraser” and “Mommy’s Big Helper.” Common side-effects include confusion, clumsiness, chronic drowsiness, impaired learning, memory and motor functions, as well as extreme euphoria, dizziness and amnesia. 

Alprazolam: Brand name Xanax, this benzo now accounts for as many as 60% of all hospital admissions for drug addiction, according to some research. What’s more, violent and psychotic responses to Xanax are not limited to humans. In May 2009, a 200-lb chimpanzee being kept as a house pet by a Stamford, Conn., woman went on a rampage after being dosed with Xanax, escaping into the neighborhood and ripping off the face of a friend of its owner.

Lorazepam: Brand name Ativan, this drug has figured in an array of well-publicized homicides and suicides by those using it. Ativan surfaced in the 2000 divorce case between Washington, D.C., socialite Patricia Duff and her husband, Wall Street billionaire Ronald Perelman. In deposition testimony, Perelman acknowledged taking Ativan as an anti-anxiety drug during his separation from Duff and the commencement of divorce proceedings. The period was marked by numerous outbursts by Perelman and at least two physical assaults on Duff. In 2008, news reports revealed that Ativan was being used by the U.S. Customs Service to keep suspected terrorists sedated while deporting them to detention facilities abroad.

You can buy any of these "feel-good" drugs without a doctor's signature by simply typing the name into any Internet search engine. Instantly, you’ll be presented with dozens of websites, both foreign and domestic, where you can make your purchase, no prescription required. (Most of the websites accept all major credit cards.)

Why has all this happened? In large measure you can thank the 47,000 members of the American psychiatric profession for this dreadful state of affairs. Neither the pharmaceutical industry nor the psychiatric profession would be anywhere near as lucrative as they are today without their mutual support system. Together they have created a marketing juggernaut that over the last 20 years has spawned a seemingly nonstop gusher of profits that is only now beginning to slow—and probably only temporarily.

The scholarly journals of the psychiatric profession were filled with early warnings, beginning almost 50 years ago, from those who could see where the encroaching influence of the drug companies was destined to lead the profession. Now, even the medical journals themselves have been corrupted by the hidden hand of Big Pharma. In 2008, the New York Times reported that a survey of the six top medical journals showed that on average almost 8% of the bylined articles published in their pages were ghostwritten by freelance writers, then published under the names of cooperating doctors and researchers to give the pro-drug messages contained in the articles the appearance of impartiality. The scheme is bankrolled, of course, by the company that makes the drug.

Consider Dr. Joseph Biederman, the world-renowned Harvard University psychiatrist and father of modern psychopharmacology for children, who, it now turns out, has been taking secret “consulting fees” from drug companies for years. Biederman is widely credited with legitimizing the concept of “bipolar disorder” as a chemical imbalance in the brain that can be corrected with psychiatric drugs. But documents uncovered by Senate investigators probing ties between the psychiatric profession and the drug industry, which have resulted in an explosion in medically approved uses for psychiatric drugs for children, show that Biederman received more than $1.6 million in undisclosed payments since 2000 from the pharmaceutical companies manufacturing the drugs he was encouraging parents to give to their children if they appeared to be “bipolar.”

No surveys that I am aware of have ever been conducted regarding the public’s impression of what psychiatrists actually do. But from pop culture media characters such as the fictional female psychiatrist Dr. Jennifer Melfi in the HBO series The Sopranos, the general belief seems to be that psychiatrists are learned and humane professionals who counsel their patients through hour-long “talk therapy” sessions in their offices once a week, and more frequently than that if necessary to help them resolve their conflicts.

In fact, many do nothing of the sort. It may be only a patient’s first session with a psychiatrist that lasts any meaningful amount of time. In this initial consultation the psychiatrist relies on the DSM manual as the diagnostic tool to decide precisely what the patient suffers from. Once that is established, the psychiatrist can begin prescribing psych meds as therapy, free of fear about the danger of a medical malpractice suit lurking down the road.

The follow-up sessions (weekly, monthly, etc.) that come after the initial consultations—that is, the sessions that are portrayed on The Sopranos as the occasions when Mafia killer Tony Soprano sits down in Dr. Melfi’s darkened office and pours out his guts about his troubled childhood—usually last as little as 15 minutes. During these so-called “med checks,” a psychiatrist typically charges $100 or more for asking the patient little more than how he or she is responding to the prescribed medication—a question that can usually be answered by a quick glance at the patient’s demeanor.

At the end of such a med-check, the psychiatrist may decide to renew the patient’s current prescription, substitute or add a new one—or even offer the patient a free sample of some new psych-med, courtesy of a sales rep from a pharmaceutical company. At four med-checks per hour, a psychiatrist with enough patients to fill up his workdays can easily make $120,000 annually from his med-check practice alone and still take a month-long summer vacation.

It's obvious that this system incentivizes doctors financially to keep prescribing drugs in order to keep patients returning for med-checks. But Big Pharma offers a whole host of additional income opportunities. Last year, ProPublica, the Pulitzer Prize–winning public-interest investigative website, did an extensive report on the financial compensation drug companies shower on physicians. Well-titled “Dollars for Docs,” this series included a database of more than 17,000 doctors who accepted “speaker fees” and other money from eight drug companies in 2009 and 2010 totaling $320 million.

That accounting is only the tip of the iceberg, however, as most pharmaceutical companies have refused to disclose their physician payments. Not surprisingly, most doctors interviewed by ProPublica denied that their medical decisions and prescribing habits were influenced by drug company payments. The new healthcare reform bill calls for greater transparency, requiring all drug-makers to disclose all fees paid to all doctors by 2014. Until then, you can type your doctor’s name into the database to find out if he or she is on the pharma take, and for how much.

Christopher Byron is a prize-winning investigative journalist and New York Times best-selling author. His columns and articles have appeared in a dozens of major publications, including New York Magazine, Fortune, The New York Times and The New York Post. He has also been a regular guest commentator on CNN. Fox, and CNBC. This article is exclusively excerpted from his forthcoming book,  Mind Drugs, Inc.: How Big Pharma and Modern Psychiatry Have Corrupted Washington and Destroyed Mental Health in America.

At Hadamar, opiates were used in conjunction with sedatives to kill.

These are powerful drugs. If it looks like a spade, then dig the grave...